Telemedicine in Pediatric Surgery.Pdf

Journal of Pediatric Surgery 54 (2019) 587–594

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Journal of Pediatric Surgery

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Telemedicine in pediatric surgery

Matthew T. Harting a,⁎, Austin Wheeler a,ToddPonskyb, Benedict Nwomeh c,ChuckL.Snyderd, Nicholas E. Bruns e, Aaron Lesher f, Samir Pandya g, Belinda Dickie h, Sohail R. Shah i, for the APSA Informatics and Telemedicine Committee a Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and Children’s Memorial Hermann Hospital, Houston, TX b Division of Pediatric Surgery, Akron Children’s Hospital, Akron, OH c Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH d Department of Pediatric Surgery, Childrens Mercy Hospital, Kansas City, MO e Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH f Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC g Division of Pediatric Surgery, Department of Surgery, UT Southwestern Medical Center and Children’s Medical Center, Dallas, TX h Department of Surgery, Boston Children's Hospital, Boston, MA i Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX article info abstract

Article history: Importance: Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, Received 30 January 2018 optimize efficiency, minimize cost, and enhance patient satisfaction. Received in revised form 13 April 2018 Objective: To review the current spectrum, potential strategies, and implementation process of telemedicine in Accepted 28 April 2018 pediatric surgery. Design: Review and opinion design. Key words: Setting: n/a. Telemedicine Telehealth Participants: n/a. Virtual visit Main outcomes and measures: n/a. Pediatric surgery Results: n/a. Technology Conclusions and relevance: Telemedicine is an emerging approach with the potential to facilitate efficient, cost- effective delivery of pediatric surgical services. Brief Abstract: Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. The objectives of this review are to explore common terms in telemedicine, provide an overview of current legislative and billing guidelines, review the current state of telemedicine in surgery and pediatric surgery, and provide basic themes for successful implementation of a pediatric surgical telemedicine program. Type of Study: Review. Level of Evidence: Level V. © 2018 Elsevier Inc. All rights reserved.

Contents

1. Deﬁningtelemedicine...... 588 1.1. Glossaryofterms...... 588 1.2. Overviewoftelemedicine...... 589 1.3. Overviewoftelementoring...... 589 2. Guidelines,legal/regulatoryissues,andbilling/reimbursement...... 589 2.1. Guidelines...... 589

⁎ Corresponding author at: Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 5.233, Houston, Texas 77030. Tel.:+1 713 500 7300. E-mail address: [email protected] (M.T. Harting).

2.2. Legalandregulatoryissues...... 589 2.2.1. Cross-statepractice...... 589 2.2.2. Credentialingandgrantingprivileges...... 590 2.2.3. Informedconsent...... 590 2.2.4. Documentation...... 590 2.3. Billing&reimbursement...... 590 3. Currentstateoftelemedicineinsurgeryandpediatricsurgery...... 591 3.1. Telemedicineinsurgery...... 591 3.2. Currentandemergingutilizationoftelemedicineinpediatricsurgery...... 591 3.2.1. Telementoring...... 592 3.2.2. Pre-andpostoperativevisits...... 592 3.2.3. Directprimarycareconsultation...... 592 3.2.4. Remotepatientmonitoring...... 592 3.2.5. Burncare...... 592 3.2.6. Emergencyroomandurgentcaretriage...... 592 3.2.7. SurgicalconsultationtocommunityICUs...... 592 4. Implementationofapediatricsurgerytelemedicineprogram...... 592 4.1. Whyincorporatetelemedicineintoyourpractice?...... 592 4.2. Initialsteps...... 593 4.2.1. Developavision...... 593 4.2.2. Institutionalandproviderbuy-in...... 593 4.2.3. Knowyourspecialtyandenvironment...... 593 4.2.4. Decide on the application that ﬁtsyourvision...... 593 4.2.5. Chooseyourtechnology...... 593 4.2.6. Developmetrics...... 593 5. Patientperceptionsandexperience...... 593 6. Conclusions...... 594 Acknowledgments...... 594 References...... 594

Telemedicine is defined as the use of electronic information and Telesurgery is remote operating through the use of a surgical robot communication technology to provide and support health care when actively controlled by a distant operator [4]. distance separates participants [1]. As technology has advanced, the op- Telementoring is performed by an expert that instructs, guides, and/ portunity to apply this technology to the delivery of health care has or teaches another individual, usually less skilled in that field or specific emerged, overcoming previous barriers to healthcare with the potential procedure, from a remote location via a live audio and/or video feed [5]. to facilitate efficient, convenient, and/or cost-effective interactions be- Distinct from this is teleproctoring, where supervision/assessment of a tween providers and patients. procedure occurs from a distance using telecommunication technology. Pediatric surgery is a field where highly-specialized care is delivered Telemonitoring is an application of telemedicine in which physiolog- by a limited number of providers, to patients and families who often ical and biological data are transferred from the patients’ home, travel a significant distance to seek expertise. In the US, data suggest intensive care unit, or other location, to a unique, specialized center there are more than an adequate number of pediatric surgeons to care for the purpose of monitoring patients, interpreting the data, and for these patients [2]; however, geographic disparities in the distribu- making clinical decisions [6]. tion of surgeons have created gaps in access to care. Therefore, the dis- Teleconsultation is a consultation by remote telecommunications, tance and travel time necessary to receive pediatric surgical care remain generally for the purpose of diagnosis or treatment of a patient at a a burden for many children, families, and providers. Telemedicine has site remote from the patient or primary physician. the potential to transform the way pediatric surgical providers interact Distant site is the location where the provider (physician, advanced with their patients, alleviating a significant part of the burden by practitioner, nurse, or other member of a medical team) delivering the adopting and integrating technologic tools to facilitate the provider– service is located at the time the service is provided via telecommunica- family–child relationship. tions system. Other common names include provider/physician site, hub The objectives of this review are to explore common terms in tele- site, specialty site, referral site,orconsulting site. medicine, provide an overview of current legislative and billing guide- Originating site is the location where the patient or relevant informa- lines, review the current state of telemedicine in surgery and pediatric tion is located or originating from, usually separate from the location of surgery, and provide basic themes for successful implementation of a the physician, provider, or medical team. Other common names include pediatric surgical telemedicine program. rural site, spoke site, remote site,orpatient site. Telefacilitator is a healthcare professional, such as a registered nurse, present at the remote site with the patient who operates, and is familiar 1. Defining telemedicine with, the technology necessary for the telecommunication, in addition to assisting with data gathering and components of the physical exam [7]. 1.1. Glossary of terms Synchronous is the delivery of telemedicine when the health care professional has direct audio/video contact with the patient [3]. Telemedicine is the rapid access to shared and remote medical exper- Asynchronous is the delivery of telemedicine when information is tise by means of telecommunication and information technologies, no acquired in one location and reviewed in a fashion where time is matter where the patient or relevant information is located [3]. Though incongruent [3]. many nuanced definitions exist, the common themes include the use of Store-and-forward refers to an asynchronous telemedicine encounter technology, the existence of distance between two parties, and the de- where information is acquired in one location and then reviewed in a livery of health care. fashion where time and location are incongruent [8]. M.T. Harting et al. / Journal of Pediatric Surgery 54 (2019) 587–594 589

1.2. Overview of telemedicine Table 1 Summary of the American Telemedicine Association (ATA) guidelines for the practice of telemedicine. Telemedicine is the use of computer-based technologies to manage a patient’s health by exchanging medical information over a distance [7]. 1. Providers must follow regulatory and licensure requirements, delivering care In the 21st century, the use of technology has exponentially increased, within the scope of their certification, training, and qualifications. becoming ubiquitous with ready access to smart phones, tablets, 2. The patient must be physically located in a jurisdiction where the provider is licensed and credentialed. laptops, and wireless connectivity. The exploitation of this technology 3. Providers must inform and educate the patient about the nature of telemedicine facilitates the ability for patients to access a health care professional services compared to a traditional encounter including: and aims to establish patient care in places and circumstances that A. Limits to confidentiality with electronic communication would otherwise prevent, or severely impair, the patient’s access to a B. A backup plan for technical or other challenges fi C. Appropriate expectations for the encounter healthcare system or speci c expertise. However, the use of telemedi- D. The expectation of a professional environment including privacy and lack of cine precedes the technology we currently use to facilitate modern distraction delivery of care and virtual encounters. 4. Services must be culturally competent, including issues of gender, orientation, In the early 1900’s, a Dutch physiologist developed the first electro- location, religion, and socioeconomic status. cardiograph and transmitted it via telegraph in 1906 [3]. As the technol- 5. Providers and patients should be able to converse in a language appropriate for both, with the use of a translator as needed. ogy advanced, so did the applications of telemedicine. Norwegian 6. Privacy and confidentiality requirements stipulated by HIPAA must be followed. physicians in the 1920’s used radios to advise sick crewmembers on 7. Devices used for medical encounters should have appropriate physical and ships on how to manage healthcare [3]. The Australian Royal Flying technical safeguards to minimize the risk of data compromise. Doctor service provided consultations using Morse code and voice 8. Patients should be made aware of potential costs of care. 9. Providers should ensure that they have the technical capability necessary to radio in 1928 [4]. Dr. Michael DeBakey used videoconferencing to conduct an encounter specific to the needs of the specialty (ie quality of image, display an open-heart aortic valve replacement being performed at specific radiographic imaging, stethoscope, etc). The Methodist Hospital in Houston, Texas to physicians in Geneva via satellite in 1962 [9]. In 1967, Bird and colleagues used audiovisual microwave circuits to consult and evaluate more than 1000 patients in Logan Airport from their location in Massachusetts General Hospital in surgery. The guidelines summarized in Table 1 are those that have Boston [3]. These early breakthroughs were the birth of telemedicine, been established by the ATA for primary and urgent care and, as of the but widespread application, to a myriad of situations and circumstances, present time, should be applied to the practice of telemedicine in in various forms, emerged from infancy over the last decade with rapid pediatric surgery. advances in audio, video, and wireless technology. 2.2. Legal and regulatory issues 1.3. Overview of telementoring Regulations for practicing telemedicine are currently handled at the When expertise and/or experience is limited at a remote site and a state level. These regulations are created by individual state law and distant provider can add valuable (sometimes critical) knowledge state medical board requirements. Each state legislature enacts laws and/or insight, telementoring can bridge the gap. The term often implies governing health care in their state, while the authority to implement a procedure-based specialty consultation, though it can certainly be these acts and oversee providers is delegated to state licensing boards. applied in any specialty. Although telementoring has been occurring in- Providers practicing medicine, including telemedicine, must be licensed formally via telephone for many years, in 1996 Moore performed formal in the state in which they practice. Each state may also have additional telementoring in 23 urological operations using the AESOP system [10]. specific requirements for telemedicine, including who may practice Telementoring allows an experienced surgeon to guide and assist those telemedicine (i.e., provider type or specialty), the originating site training and performing an operation remotely through the use of tech- (where the patient is located), type of visits allowed, ability to prescribe nology. Traditionally, surgical training is overseen and administered by medications, and/or reimbursement requirements. Additional impor- in-house faculty but can be limited to the number of experienced faculty tant regulatory issues that must be considered when practicing at a given institution. Remote mentoring allows trainees to expand their telemedicine include cross-state practice, credentialing and granting range of mentors. In order for this application of telemedicine to be ef- privileges, informed consent, and documentation requirements. fective, there is usually a synchronous form of communication between the two parties in which instant exchange of information can occur [4]. 2.2.1. Cross-state practice Telemedicine facilitates the possibility for providers to practice 2. Guidelines, legal / regulatory issues, and billing / reimbursement medicine in several states without travel. However, providers must be aware of specific regulations that affect cross-state practice. When a 2.1. Guidelines provider is located in one state and the patient is located in another, the originating site (location of the patient) is considered the location The American Telemedicine Association (ATA) is an organization where the provider is practicing medicine. In this situation, the distant that consists of healthcare professionals, technology and telecommuni- site provider must be licensed in and follow all regulations of the state cations companies, and government officials who have a similar goal to in which the patient is located. improve the delivery of healthcare [11]. Guidelines involving the use of To alleviate the licensure burden, some state medical boards issue telemedicine were first established by the ATA in 1999 and were spe- specific licenses and/or certificates related to telemedicine that may cific for the field of telepathology [12]. These guidelines were developed allow out-of-state providers to avoid having to obtain full, unrestricted through a process involving rigorous review which resulted in a general licensure just to practice cross-state telemedicine. Additionally, the consensus. The ATA board of directors ultimately approved the set of Federation of State Medical Boards has created the Interstate Medical proposed guidelines and continues to review and update the guidelines Licensure Compact to expedite licensure for qualified physicians who periodically based on current literature in the fields of telemedicine as practice in multiple states. The Compact is an agreement between 22 well as feedback from special interest groups, corporate partners, states whereby licensed physicians can qualify to practice medicine and institutional members [11,12]. Although guidelines have been across state lines within the Compact if they meet eligibility criteria [13]. established for many different fields of medicine, the ATA has not Some states make further exceptions to these cross-state licensure established guidelines directed at the practice of telemedicine in requirements. However, these exceptions are limited and vary from 590 M.T. Harting et al. / Journal of Pediatric Surgery 54 (2018) 587–594 state to state. Examples of some licensure exceptions include physician- In 2014, 68,000 Medicare Part B fee-for-service beneficiaries re- to-physician consultations (i.e. telementoring), medical emergencies, ceived some form of telemedicine service. Of those who received and educational purposes. A good resource for updated licensure re- these services, 42% of these telemedicine encounters were located quirements is http://www.cchpca.org/state-laws-and-reimbursement- within 10 states, revealing that there is an unequal distribution of policies [13]. telemedicine services throughout the country. These patients who had access to telemedicine averaged three telemedicine visits per year and fi 2.2.2. Credentialing and granting privileges Medicare spent an average of $182.00 per bene ciary [16]. Although Providers that practice telemedicine must also have privileges to Medicare does not have a special category for remote patient monitor- practice medicine at any hospital that acts as the originating site for ing, these services can be bundled with other services in order to be the patient. However, the process of credentialing and granting covered. Medicare spent $119 million on remote cardiac monitoring privileges for every distant site provider that offers telemedicine consul- services for 265,000 patients and $70 million on remote monitoring of tation to a hospital can become quite burdensome. For this reason, there heart rhythms for 639,000 patients in 2014 [16]. Telemedicine, is an option for an originating site hospital to “privilege by proxy”. In this however, only makes up a small portion of total of Medicare claims situation, the hospital receiving telemedicine services may accept the each year. credentialing and privileges decision from the distant site hospital if There are several barriers within Medicare and its involvement with fi certain requirements are met. However, this option also has to align telemedicine services that have been identi ed. The coverage has been with the hospital bylaws, along with state laws and regulations [14]. noted to be the single greatest barrier, as Medicare places restrictions on the types of telemedicine services covered [16]. Other barriers that have been identified include Medicare’s location requirements, cost increases 2.2.3. Informed consent or inadequate payment, provider and patient training requirements, Federal law does not require informed consent specific to the use of cultural factors, equipment costs, and professional licensure issues [16]. telemedicine; however, some states have requirements by regulation The Centers for Medicare and Medicaid Services (CMS) do not limit and/or Medicaid policies. Under these circumstances the provider the use of telehealth and remote patient monitoring in Medicaid. must receive and document informed consent, specifically addressing Instead, each individual state may determine any restrictions and telemedicine, from the patient prior to the use of telemedicine [13]. limitations for telehealth coverage. Reimbursements from Medicaid vary widely from state to state. Each state has its own definitions 2.2.4. Documentation regarding what constitutes telemedicine, and which services may Federal health oversight agencies including the Joint Commission qualify for reimbursement. In fact, states even differ in their use and fi and US Department of Health and Human Services do not speci cally definitions of terminology such as “telemedicine” or “telehealth”.In address any documentation requirements for telemedicine visits. some states “telehealth” is used to incorporate a broader meaning Therefore, a telemedicine encounter should be documented and the while “telemedicine” specifies the delivery of clinical services [17]. health record maintained in the same manner as an in-person visit. As of April 2017, 48 states and the District of Columbia provide some Additional information that is recommended to be included in the form of reimbursement for telehealth services through their Medicaid documentation is that the visit was conducted by telemedicine, the pa- program. The two states without written reimbursement policies are ’ tient location (originating site), the provider s location (distant site), Massachusetts and Rhode Island. However, some states utilize broad and the names and roles of all people present during the visit. If in- regulatory statements that do not provide specific reimbursement pol- formed consent is necessary by state regulations or institutional policy, icy, which results in policy that is vague and open to interpretation. then it should be documented and maintained as part of the health Live video is the most widely accepted telehealth modality amongst record [15]. Medicaid programs. Every state that offers telehealth reimbursement through their Medicaid program includes some form of reimbursement 2.3. Billing & reimbursement for live video. However, there is substantial variation in regards to what services are eligible and how the services will be reimbursed. Variations The nuances of billing and reimbursement are highly varied and de- in telehealth coverage by states include the specialties covered, types of pendent on both payer and location. The billing and reimbursement services reimbursed (i.e., office visit, inpatient consultation, etc.), types landscape of telemedicine is dynamic and constantly evolving as of providers reimbursed (i.e., physician, advanced practice provider, telemedicine gains more popularity, is being embraced by patients, nurse, etc.), and the location of the patient (originating site). and is being increasingly adopted by practitioners and institutions. Store-and-forward, an asynchronous telehealth application, is The United States Government Accountability Office (GAO) recently re- further limited by many state Medicaid programs. As of April 2017, ported to congressional committees the current state of telehealth and only 13 states provide reimbursement for store-and-forward telehealth remote patient monitoring use in Medicare, Medicaid, and other se- services, and many of these states have further restrictions including lected federal programs [16]. While these reimbursement policies may approved specialties and types of services. differ from individual commercial payers, their findings do demonstrate Remote patient monitoring is currently only approved for reim- the variation and constant evolution of coverage for telehealth services bursement in 22 states. However, many of the states have several re- [16]. strictions including which clinical conditions can be monitored, and Medicare, which provides health coverage for people over the age of the type of monitoring device and the information collected, and some 65, individuals with certain disabilities, and individuals with end stage only offer reimbursement to home health agencies. renal disease, began paying for telemedicine services after the passage Currently private payer reimbursement policies for telehealth vary of the Balanced Budget Act of 1997. This statute required Medicare to across the country. There are 35 states that have laws governing these pay for services such as consultations, office visits, and outpatient psy- policies; however, not all mandate reimbursement. Additionally, there chiatry services using real-time audio/visual telecommunications [16]. is variation in whether the amount of reimbursement for services However, Medicare requires that the originating site (location of the delivered via telehealth has to equal the reimbursement for services patient) must be a medical facility (hospital, clinic, or skilled nursing delivered in-person. facility) located in a rural health professional shortage area. The distant The Center for Connected Health Policy provides an annually up- site provider is paid the same rate for services delivered by telemedicine dated resource summarizing telehealth-related laws, regulations, and services as they would be paid for the same in-person service. The Medicaid coverage for all 50 states and the District of Columbia originating site is paid a facility fee of $25.00 [16]. (http://www.cchpca.org/state-laws-and-reimbursement-policies). M.T. Harting et al. / Journal of Pediatric Surgery 54 (2019) 587–594 591

3. Current state of telemedicine in surgery and pediatric surgery Many studies have evaluated the use of telephone calls, videoconfer- ences from a remote site, collection of data via text messaging such as There are a variety of applications of technology and telehealth in daily surgical drain output, spirometry results, symptoms, blood the practice of medicine and these are often different based upon the pressure and adherence to medications, and digital photography [19]. specific field, the setting, and/or the institution/provider. These uses in- A recent systematic review of telemedicine for postdischarge surgical clude using mobile phones to take and send images, using telephones care revealed that outcomes were comparable between telemedicine for consultations, e-mail use, live feed videoconferencing with patients and usual care, and that no difference in the rate of complications ap- or colleagues, monitoring patients at home with chronic conditions, peared to result from the use of a telemedicine approach [19].Notably, intensive care unit (ICU) monitoring, surgical consultation, post- the majority of studies reported significant time, travel, and resource operative care, and many other uses of technology to aid the physician savings to patients and their families without compromising clinical in communication with patients, other physicians, or associate pro- outcomes. Moreover, both patients and providers reported high satis- viders. Generally, telemedicine can be divided into four broad categories faction and could clearly comprehend the benefit of incorporating tele- including real-time or synchronous, store-and-forward or asynchro- medicine into a postoperative care program. Hwa et al used telephone nous, remote patient monitoring, and mobile health [18]. calls for postoperative follow-up visits after umbilical hernias and lapa- Real-time or synchronous telemedicine has a multitude of uses and roscopic cholecystectomies, which resulted in no complications and is generally the main modality that comes to mind when referring to opened 110 clinic spots over a 10-month period [20].Vieresetalused telemedicine. This modality uses live audio and video feeds to link two video conferencing after radical prostatectomies for follow-up and providers together or a provider to a patient. This allows for found no urologic complications over a 3 month period, higher patient telementoring between two physicians during an operation as and provider satisfaction, and overall equal efficacy to clinic visits [21]. mentioned previously, as well as teleconsultations and/or education be- In another study, simply using mobile phone-based telemedicine tween two providers. Real-time telemedicine can be used in the clinic during the postoperative course to assess and monitor for surgical setting preoperatively to diagnose a patient and determine if an wound complications resulted in rapid resolution of common postoper- operation is necessary and can also be used in the postoperative setting ative questions [22]. If patients were concerned with their surgical to follow patients and monitor their recovery. This is the most common wound, they were instructed to contact the surgical team via phone modality reimbursed by health care plans, as discussed earlier [16–18]. and then to take pictures of the area on their phone and send it to the Store-and-forward, an asynchronous modality, involves using surgery team. These images were viewed and examined by three physi- computers, email, or mobile phones to capture and deliver medical cians who would then contact the patients and instruct them on what information such as images and send them to a specialist or physician steps they should take to resolve their complaint. In this study, 225 pho- at another location [3,8,18]. tographs were examined owing to complications such as hematomas The remote patient monitoring modality allows physicians and (66%), bloodstains on bandages (23.3%), exudates (3.3%), allergic skin health care professionals to monitor patients electronically at another reactions (3.3%), and tight bandages (3.3%). The physicians were able location. This modality is often used in patients with chronic conditions to identify the problem in each case and resolve the patients concerns such as hypertension, diabetes, and chronic obstructive pulmonary in 66.7% of the cases. In the remaining 33% of the cases, the concerns disease [16,18]. were resolved over the following days with subsequent images [22]. Mobile health modality involves using mobile phone apps and Telesurgery is another use of telemedicine in surgery that involves online services that are available to patients allowing them to view lab the use of robotic devices that can be operated by a surgeon at a distant results, medications, appointments, and other details involved in their location. Robotic devices such as the Zeus system and the da Vinci sur- health and recent physician encounters [18]. gical system are the most robust and widely-adopted systems. In 2001, the first transcontinental telesurgical operation was performed 3.1. Telemedicine in surgery using the ZEUS system, in which a laparoscopic cholecystectomy was successfully performed in Strasbourg, France while the surgeon oper- There are increasing reports of telemedicine being utilized in adult ated the system from New York, USA [4,23]. surgical specialties. The specific modality utilized varies widely from The Zeus System consists of the “patient side” and the “surgeon side” pre- and postoperative visits to a few very early applications of that are connected through asynchronous transfer mode technology telesurgery. These applications also vary in their use of synchronous, (ATM). On the side of the patient, two robotic arms are present allowing real-time audio/visual technology and store-and-forward, asynchro- for control of the endoscopic camera on one arm and on the other a nous technology. plethora of instruments can be interchanged, dependent on those re- Synchronous telemedicine uses technology that allows patients and quired to complete the surgery. The surgeon at the “surgeon side” providers to communicate through both audio and video, providing operates these robotic arms in a nonsterile environment at a separate visualization of the patient and expanding the amount of information site. The two sites are also connected through videoconference to that is exchanged between provider and patient. It has been discussed allow for communication [23]. The da Vinci® surgical system is also a how this form of communication can be extremely useful within the surgical robot similar to the Zeus® System. This robotic system operating room, but it has a potentially broad array of applications in has two arms for surgical instruments that have unique ends called both the preoperative and postoperative periods. “endo-wrists” that allow for seven degrees of movement and another During the preoperative period, the physician is now able to arm for an endoscopic camera [5]. Despite incredible advances that evaluate possible candidates for surgery who are in rural or remote lo- allow for the possibility of operations performed by a surgeon from a cations, without local access to a surgeon. With the use of synchronous distance, limitations of patient size and the need for bedside surgical ex- video and audio feeds, physicians are now able to witness and guide a pertise in the event of a surgical complication or technical failure, render physical exam, performed by the telefacilitator at a remote site. The routine or daily telepediatric surgery a target with some significant telefacilitator, generally a registered nurse or other specialist, is present barriers yet to be overcome. with the patient during the encounter and is also responsible for han- dling the equipment at the remote site [7]. 3.2. Current and emerging utilization of telemedicine in pediatric surgery In the postoperative period, physicians are able to follow-up with patients and manage their care from a distance. This can become The use of telemedicine in pediatric surgery continues to grow and extremely useful for patients who do not live in close proximity to the evolve. Although there are currently few published reports demonstrat- surgeon’s practice or the center where the operation was performed. ing the use of telemedicine in the pediatric surgical population there are 592 M.T. Harting et al. / Journal of Pediatric Surgery 54 (2018) 587–594 numerous growing programs around the United States. Current and new burns to ensure patients receive care at appropriate facilities, and emerging uses included telementoring, pre- and postoperative telemonitoring outpatient burns. medicine visits, direct primary care consultation, remote patient monitoring, burn care, emergency room and urgent care triage, and surgical consultation to community ICUs [24–26]. 3.2.6. Emergency room and urgent care triage Several health care systems have begun to use telemedicine to assist 3.2.1. Telementoring in triaging patients presenting to local emergency rooms and urgent Current applications for telementoring in pediatric surgery tend to care centers. Often the goal of these centers is to expedite surgical include rare, technically challenging cases that are approached in a specialty consultations to determine treatment recommendations, minimally invasive fashion (i.e. laparoscopy, thoracoscopy) where the need to transfer to a higher level of care, or appropriate outpatient primary surgeon has suboptimal experience with the technique. management. The most common application is for isolated trauma in- Minimally invasive approaches are more conducive to surgical cluding, burns, fractures, wounds / lacerations, and closed head injuries fi telementoring because the video feed can be simply reproduced for without radiographic ndings. Further, the feasibility of using a robotic the telementor to see, and, with telestration abilities, the telementor telecommunications system to provide remote triage and expert con- can annotate over the endoscopic images for further clarity. sultation has been demonstrated in pediatric mass casualty situations Telementoring should be implemented in a responsible fashion: it is [24]. not a replacement with in-person training or courses, but rather should be an adjunct to the above methods to improve the learning curve for a 3.2.7. Surgical consultation to community ICUs technique in which the telementee has a baseline experience but To meet requirements of verification programs, some institutions there is no local mentor. Published pediatric surgical cases that have have opted for a virtual surgical presence in their ICUs. This has led to been telementored include laparoscopic gastrointestinal surgeries, a greater number of neonatal and pediatric ICUs using telemedicine to laparoscopic inguinal hernia repairs, thoracoscopic lung resections, provide surgical consultations for their critically ill patients. This pro- thoracoscopic mediastinal mass excision, and thoracoscopic congenital vides these institutions greater opportunity to appropriately determine – diaphragmatic hernia repair [27 29]. Obstacles for telementoring in- when a patient may need to be transferred for surgical issues and keep clude a lack of legislation regarding the medicolegal liability of the the children that may not need surgical intervention. telementor as well as no current financial model (ie no billing code) to compensate the telementor for his or her time. 4. Implementation of a pediatric surgery telemedicine program 3.2.2. Pre- and postoperative visits Telemedicine has been successfully used for initial pediatric surgical 4.1. Why incorporate telemedicine into your practice? consultation and postoperative care [30]. One of the more common uses is a “hub and spoke” design, where the pediatric surgical subspecialist is As immediate access to goods and services becomes ubiquitous, the at a centralized “hub” location (i.e., tertiary care children’shospital)and desire for immediate access to healthcare continues to mount. the patients present to remote sites (“spoke”) closer to home. At the re- Healthcare is rapidly evolving, with patients continuing to expect opti- mote site a telefacilitator works with the patient and is able to assist mized quality and efficiency, payers decreasing reimbursement, and with the physical exam under direction of the distant provider at the physician demands ever increasing; telemedicine can have a profound, centralized “hub” through a two-way real-time audio/visual connec- positive effect on all these forces. Telemedicine can allow providers and tion. The remote sites are often clinic space owned or leased by the sub- systems to get the right patient, to the right place, at the right time, so specialty provider’s institution. that appropriate expertise is available to ensure that optimal care is Another emerging application for postoperative visits is conducting provided. A summary of proposed benefits and barriers/challenges to a telemedicine visit directly to the patient’s home. This has been used practicing telemedicine is shown in Table 2. after select routine pediatric surgical procedures with success at several institutions (MTH and CLS institutions). Advantages include enhanced patient experience, family/patient cost savings, and potential institu- Table 2 fi fi Summary of proposed bene ts and barriers/challenges to incorporating telemedicine tional bene ts of improved access through additional open clinic slots. into a pediatric surgical practice.

3.2.3. Direct primary care consultation Benefits 1. Increased access to / reach of pediatric surgical expertise: In a delivery model similar to the “hub and spoke” design discussed A. Geographically above, some pediatric surgical providers offer direct consultation to se- B. Economically lect primary care offices. In this situation, the primary care office staff C. Temporally (nurses, advanced practice providers, or physicians) may act as the 2. Increased patient convenience 3. Optimize patient and family engagement telefacilitator and consult directly with a surgical specialist while the fi fi 4. Increased physician ef ciency patient is in their of ce. 5. Potential to decrease health care costs A. Patients/families 3.2.4. Remote patient monitoring B. Hospital, hospital systems, and institutions Remote patient monitoring is a growing trend in pediatric surgical C. Payers 6. Standardization of care patients. This technology allows providers to monitor patients at 7. Opportunity to optimize quality of care home through both synchronous and asynchronous applications. 8. Enable consistent monitoring and longitudinal data collection/follow up Monitoring tools may include pulse oximetry, vital signs, weight, feed- Barriers and Challenges ing patterns, video uploads, incision checks, etc. 1. Licensure 2. Provider and administrative buy-in 3. Credentialing and bylaws 3.2.5. Burn care 4. Reimbursement Telemedicine for pediatric burns offers the ability to expand the out- 5. Medicolegal and malpractice concerns reach of the limited number of pediatric burn specialists. Applications 6. Technological (both hardware and software) and connectivity limitations include burn specialists monitoring inpatient burn debridements and 7. Patient and family acceptance 8. Physical examination limitations wound care without having to be physically at the bedside, triaging M.T. Harting et al. / Journal of Pediatric Surgery 54 (2019) 587–594 593

4.2. Initial steps metrics can be broadly divided into three categories: patient perspective, provider perspective, and institutional perspective. Examples of Initiating a program in telemedicine, or simply establishing the ca- patient perspective metrics include cost / travel / time savings, access pacity to see patients at a distance, can seem daunting to a provider to care, and patient experience. Examples of provider perspective unfamiliar with the processes, regulations, nuances, and technology metrics may include efficiency, effects on outreach, or specific program involved in programmatic development and implementation of growth. Examples of institutional perspective metrics may include telemedicine services. These steps are common to general program de- patient access, market share, new revenue (direct and downstream), velopment, with a few nuances specific to (tele) medicine. decreased expenses, or patient experience evaluations.

4.2.1. Develop a vision 5. Patient perceptions and experience What patient population are you trying to serve? What is the local/ regional institutional, provider, and payer landscape? A successful pro- Patient satisfaction and eagerness to use and accept telemedicine as gram starts with an idea about who, exactly, you want to connect, on a standard of care are still uncertain and assessment of patient’sviews both the provider and patient side. That idea should grow into a vision and understanding is highly dependent upon many factors. In a study based on a multitude of surrounding factors including the region, insti- in Ontario, Canada, a survey measured family costs and attitudes toward tution, providers, politics, resources, and technologic opportunities. telemedicine alternatives in pediatric urology and general surgery outpatient clinics [31]. Of the families that took the survey, around twenty 4.2.2. Institutional and provider buy-in percent traveled more than 200 km round-trip for an appointment at The most critical and foundational step to developing a successful tele- the clinic and over ten percent of families use several means of transpor- medicine program is initial institutional and provider buy-in. Both parties tation. A common complaint was that the cost of hospital parking is too should have alignment in their vision, strategy, and goals for the program. high and parking rates should be reduced. In 75% of the families, at least The institution should be prepared to support the program from initial one parent had to miss work to attend the clinic visit and in 25% of fam- implementation through later growth phases. This support needs to ilies both parents had to miss work. It was found that both parents were consist of financial, technical, and administrative operational support/ more likely to miss work with increasing travel distance. Nearly twenty resources. Administrative or institutional champions must see the long- percent of families also perceived the cost of the visit “somewhat high” term vision and understand the likely short-term challenges. From the and 9.6% of families perceived the cost of the visit “high” when all costs provider side, there does not need to be buy-in from every provider across were factored in including the cost of travel, lodging, babysitters, food, the institution. However, there must be physician champions in key target parking, missing work, etc. In regards to telemedicine, families felt areas that are identified as interested and willing personnel opportunities comfortable or extremely comfortable communicating with healthcare for telemedicine development/implementation. professional through email (69.9%), telephone (82.9%), and video conferencing (52.9%). In comparison, the majority did not want to sub- 4.2.3. Know your specialty and environment stitute a visit with the use of email, telephone, or video conferencing. Of Every specialty has a unique patient population and a thorough un- those who stated that they would be comfortable substituting an inpa- derstanding of the patients and disease processes will guide appropriate tient visit with use of telemedicine, 34.3 % were comfortable with email. development of telemedicine opportunities. One of the earliest steps 42.7% with telephone, and 38.4% with video conferencing. Patients who (possibly even before Institutional and Provider Buy-in) is to under- were familiar with these telemedicine services were more like to be stand the legal and regulatory environment of your state. Each state willing to substitute a clinic visit with telemedicine communication; has different telemedicine regulations, as discussed above. There however, only twenty percent of those families in the survey were fa- needs to be a clear understanding of state regulations, state medical miliar with this method [31]. board requirements, and institutional credentialing requirements. This Gunter et al found that patients who underwent follow-ups utilizing may seem like an overwhelming task; however, there are numerous re- telemedicine applications decreased personal costs, minimized travel sources that make this information readily available (i.e., http://www. time, and decreased the need to take days off from work or miss other cchpca.org/state-laws-and-reimbursement-policies and http://www. responsibilities [19]. Surveys showed that the majority of patients americantelemed.org/home). were willing to participate in telemedicine and thought it would aid in their communication with the health care provider. Patients who had 4.2.4. Decide on the application that fits your vision already participated in a postoperative protocol reported high rates of As discussed above, there are numerous different telemedicine satisfaction and found the system easy to use. Canon et al revealed modalities available that have improved patient experience, access, and that patients were 111% more likely to prefer a remote postoperative institutional efficiency. Choose the setting and telemedicine application follow-up using telemedicine for every 23-milesincrease in distance that meets the need of your institutional vision (i.e., outpatient surgical from the site of the appointment [19]. care, remote patient monitoring, inpatient / ICU care, etc.). In study of 1734 individuals who completed a survey after receiving care through a telehealth visit at CVS minute clinics, 32% of these pa- 4.2.5. Choose your technology tients expressed a preference for receiving care via telehealth, 57% There are numerous telemedicine technologies available through stated that their telehealth visit was “just as good as a traditional many vendors. Based on your application, budget, and institutional visit”, 1% stated that it was “worse than a traditional visit” and the re- vision and growth strategy, the right technology is likely available. The mainder were unsure. In regards to the technology, 95% of patients keys to selection are to ensure a reliable platform that provides privacy were very satisfied with their ability to hear and see the health care pro- to meet HIPAA requirements, offers the ability to scale based on institu- fessional and the images on the screen and 95% of individuals stated that tional needs, and potential for peripheral add-ons (i.e., stethoscope, they were “very satisfied” with all attributes. Nearly 100% of patients digital zoom camera, otoscope, ophthalmoscope, etc.), if necessary. stated that they would recommend the use of telehealth to someone Technological support is important to consider, both for patients and else and also stated that they would use it again. However, it was providers, depending on resource availability. found that there was an inverse relationship with the high satisfaction of the assisting nurse and the satisfaction of the telehealth visit [32]. 4.2.6. Develop metrics Patient satisfaction should be highly sought in all aspects of To demonstrate success of the telemedicine program it is important medicine and ongoing assessment of patient and family perceptions of to develop early metrics that will be prospectively measured. These telemedicine is critical to optimizing applicability. 594 M.T. Harting et al. / Journal of Pediatric Surgery 54 (2018) 587–594

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